Spirals of Harm, Fear of Pedophilia, and Scrupulosity

We've all heard it. "I'm so OCD." The phrase is typically followed by a remark on how organized someone is, typically with a positive focus. While it's true that, for some, cleaning or washing rituals can be a part of obsessive-compulsive disorder, by definition, it must rise to a level that causes distress and interferes with a person's valued goals. Regardless of type, OCD is painful.

Obsessive-compulsive disorder is one of the most mysterious conditions I have come across. Its chameleon-like nature allows it to create thousands of presentations, with a smaller number of common core themes. What all manifestations share is a sense of doubt often accompanied by spirals during which uncertainty feels intolerable. In inference-based cognitive therapy (I-CBT), a psychotherapy used to treat OCD, this doubt spiral is known as the "OCD bubble" (O'Connor and Aardema, 2012). It traps a person in a space where it is difficult to keep contact with the present moment, wherein fear takes over, and getting out becomes much more difficult than falling in.

Many of the individuals I have treated for OCD had never received the diagnosis before we met and did not know that what they were dealing with even had a name. Many are frightened or confused by their experiences. Misdiagnosis of OCD with anything from generalized anxiety disorder to psychotic disorders is not uncommon, only adding to the perplexity and shame. To tangle things further, OCD rarely travels alone, so comorbidities such as generalized anxiety disorder or autism are common. Research suggests that around 13 percent of people with schizophrenia also meet the criteria for OCD (Swets el al., 2014), which is usually a complex presentation.

What follows is a description of three manifestations of OCD that are lesser known but which often cause fear, shame, and confusion.

Harm OCD

Harm OCD spirals on a thought of "What if I could harm someone?" This fear of harm could take the form of anything from accidentally (or intentionally) poisoning someone to significant violent acts. The harm in harm OCD can also be directed to the self. An individual with the condition may take unnecessary steps to avoid this, such as refusing to use kitchen knives. Others may check repeatedly to see if they have caused harm to someone (such as inspecting a vehicle for signs of a hit and run).

It's important to know that a person with harm OCD does not want to harm anyone and is rarely any danger. A person with harm OCD would hate nothing more for these thoughts to be reality. They may also experience visceral intrusive thoughts of others being in pain. These thoughts may cause a person to flinch or avoid triggers like being around vulnerable people.

Pedophilia OCD

Let me be clear: contrary to the name, pedophilia OCD is not related to true pedophilia. It describes a specific obsession wherein someone becomes fearful of being a pedophile. The words of pedophilia OCD are "What if I could be a pedophile?" The person may take part in rituals such as avoiding children and often feels an intense level of shame. People with pedophilia OCD are often hesitant to discuss their concerns with a therapist for fear of judgment. Yet, learning about this particular way OCD shows itself can be liberating.

Sometimes, a person living with pedophilic OCD will experience mental imagery they find repulsive. Part of the OCD can also be a doubt of if they truly have OCD at all. "What if I do not have OCD and am a pedophile?" is a common fear. (Bruce et al., 2018).

Scrupulosity OCD

Scrupulosity OCD features spirals on topics related to morality or religion, causing a person to fixate on a thought of "What if I violate my moral compass (or the laws of my faith)?" This can lead a person to question if they have committed a crime even if they are 98 percent sure they didn't. Guilt and self-hatred often accompany this. In the case of scrupulosity OCD, compulsions can include self-punishment.

In scrupulosity OCD, a person may be fearful of accepting help at first. Seeking treatment is not the same as letting go of one's values, it's working through the OCD so that someone can live a life more based on their values.

What can be done?

Psychotherapy Treatments

Exposure Ritual Prevention

The gold standard treatment for obsessive-compulsive disorder is exposure ritual prevention therapy (ERP). This therapy involves gradual exposure to triggers to a person's obsessions and compulsions without engaging. It can be an intense process yet yields a high success rate.

Acceptance Commitment Therapy

Acceptance commitment therapy (ACT) assists individuals in building a strategy for defusing unwanted thoughts such that the individual can watch the thoughts without becoming tied up. This creates a different way of relating to one's thoughts that places the person in charge. ACT also has a strong focus on clarifying a person's values. It can be integrated into exposure ritual prevention with values-based exposures.

OCD Essential Reads

A New Theory of OCD

Innovations in Treating Obsessive-Compulsive Disorder

Inference-Based CBT

Inference-based cognitive behavioral therapy (I-CBT) is a psychotherapy that zeros in on the doubt aspects of OCD. Exploration of self-trust alongside a set of additional cognitive behavioral interventions is also used. I-CBT is a newer approach when compared to ERP and ACT, but it is quickly gaining momentum.

In Closing

Obsessive-compulsive disorder is a complex condition that has been the target of a great deal of misunderstanding and stigma. There are several presentations of OCD, including many that fall outside what is common knowledge, even among clinicians. Misdiagnosis is frequent for people with OCD. Yet, identification of OCD is key to accessing the appropriate treatment. Psychotherapy for OCD is quite specialized, and without a proper diagnosis, recovery can be difficult.

To find a therapist near you, visit the Psychology Today Therapy Directory.